Prenatal Massage Intake Form
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Email *
Name *
Release Of Liability for Massage Services
Terms and conditions & Release of liability
Please read the terms and conditions and confirm below.   *
I understand that the massage/bodywork I receive is provided for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage/bodywork should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I understand that massage/bodywork practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage/ bodywork should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of the scheduled appointment. I have received and read written information concerning the possible benefits prenatal massage therapy. I verify that I am experiencing a low-risk pregnancy, and have stated all of my known medical conditions. I understand that I will be receiving massage therapy for the purpose of stress reduction, relief from muscle tension or spasm, and/or for an increase in circulation and energy flow. I understand that the massage therapist does not diagnose illness, and, as such, the massage therapist does not prescribe medical treatment or pharmaceuticals, nor does she perform any spinal manipulations. I am aware that this massage is not a substitute for medical examination/diagnosis and that it is recommended that I see a physician for any ailment that I may have. I understand and I agree that I am receiving massage therapy entirely at my own risk. In the event that I become injured either directly or indirectly as a result, in whole or in part, of the aforesaid massage therapy, I hereby hold harmless and indemnify the therapist, their principals, and agents from all claims and liability whatsoever.
Required
Expected Due Date *
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Week of Pregnancy *
Please check any complication or condition you may have experienced during this pregnancy: *
Required
Have you been told you are experiencing a High Risk Pregnancy?   *
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